News & Events

Senate Report Finds Insurers Wrongfully Charged Consumers Billions (MC)

By David S. Hilzenrath
Washington Post Staff Writer
Wednesday, June 24, 2009 1:01 PM

Health insurers have forced consumers to pay billions of dollars in medical bills that the insurers themselves should have paid, according to a report released today by the staff of the Senate Commerce Committee.

The report is part of multi-pronged assault today on the trustworthiness of private insurers by Commerce Committee Chairman John D. Rockefeller IV (D-W.Va.). It comes at a time when the insurance industry is battling efforts to offer consumers a public alternative to private health plans.

At a hearing this afternoon, Rockefeller’s panel is slated to air allegations by a former industry insider that insurers have put profits before people’s health.

The report released this morning alleges that insurers have systematically underpaid for so-called out-of-network care. The issue has been brought to light in past litigation and investigations, including a probe by New York Attorney General Andrew Cuomo.

Cuomo described it last year as "a scheme by health insurers to defraud consumers by manipulating reimbursement rates." A dozen insurers have reached settlements with Cuomo agreeing to change their practices.

Many Americans pay higher premiums for the freedom to go outside an insurer’s network of doctors and hospitals. When they do, insurers typically pay a percentage of what they call the "usual and customary" rates for the services. How insurers determined the usual rates had long been opaque to consumers and difficult if not impossible for them to challenge.

As it turns out, insurers typically used numbers from Ingenix Inc., which was a wholly owned subsidiary of the big insurer UnitedHealth Group. As such, Ingenix had an incentive to produce benchmarks that low-balled usual and customary rates and shifted costs from insurers to their customers, the report said.

Making matters worse, Ingenix got all of its data from the same insurers that bought its benchmark information, the report said. Insurers that contributed data to Ingenix often "scrubbed" their data to remove high charges, and Ingenix further manipulated the numbers, removing valid high charges from its calculations, the report said.

Cuomo found that insurers systematically under-reimbursed New York consumers by up to 28 percent, the report said. Earlier this month, New York’s Department of Insurance issued a regulation prohibiting insurance companies in New York from obtaining data on usual and customary charges from anyone with a conflict of interest.

In March testimony to Rockefeller’s committee, UnitedHealth Group’s chief executive expressed regret that there was a conflict of interest inherent in his company’s relationship with Ingenix, the report said.
But chief executive Stephen J. Hemsley also said UnitedHealth stands by "the integrity of the Ingenix data" and the way UnitedHealth "used the data to make reimbursement decisions." He said the company worked with Cuomo to transfer its databases to an independent, nonprofit entity.

Ingenix bought one of its original databases in 1998 from the Health Insurance Association of America, a precursor to the industry’s main trade association and lobbying group.

From a nurse blogger on the NPSF (Natl Patient Safety Foundation) listserve at:

Sandy Szwarc, BSN, RN, CCP

June 21, 2009 The importance of sound data — managing your healthcare costs

This week, Attorney General Andrew Cuomo announced that Health Net, Inc., a managed care company covering more than two million Californians and nearly a quarter million New Yorkers, had agreed to end its relationship with Ingenix and pay $1.6 million towards the creation of an independent database. This was Cuomo’s twelfth settlement against a network of health insurers across the country (including Aetna, MVP Health Care, Cigna, Wellpoint and Excellus Health Plan) using the Ingenix database, which he charged was a “conflict-of-interest-ridden system” with manipulated data and behind industry-wide consumer fraud and corrupt out-of-network reimbursement schemes.

Ingenix is owned by one of the nation’s largest insurers, UnitedHealth Group, Inc., and used by the nation’s largest managed care companies to determine reimbursement policies. Ingenix ran afoul of the Federal Trade Commission, which issued consent orders (Docket No. C-4214) against Milliman, Inc. and Ingenix, Inc. for engaging in “unfair and deceptive acts and practices.” Cuomo said Ingenix was “a conduit for rigged data” for the country’s largest third party payers, private and federal health plans and has intentionally skewed healthcare costs to bilk millions of consumers with higher out-of-pocket insurance bills and short change medical providers for expenses claimed to be over “usual and customary costs.”

Earlier this year, UnitedHealth Group had agreed to shut down Ingenix and pay $50 million towards creating an independent database, along with $350 million in class-action lawsuits.

But this story has far greater significance than is being recognized. It’s much bigger than insurance reimbursements and care management. The Ingenix database has also been used in medical research reaching spurious conclusions and supporting medical interventions, as well as public policies and healthcare reform calling for third-party payer oversight, that consistently benefit sponsoring stakeholder interests. Preserving the integrity of medical research has critical importance for the healthcare we receive and affects the lives and welfare of each one of us. The potential misuse of research to sell anything — including political agendas, healthcare reform or medical interventions — should concern everyone.

Ingenix, which says it’s a leader in health information solutions, also sells electronic medical records, and its consulting clients include more than 300 national and regional and Medicaid/Medicare managed health plans; more than 100 federal and state government agencies, and more than 50 healthcare delivery systems, including pharmacy benefit managers (PBMs).Ingenix benefited by the stimulus package, with the government making the adoption of national electronic medical records and preventive wellness programs key parts of organized efforts towards healthcare reform. Tom Daschle — former Senate Majority Leader and the President’s originally designated Health and Human Services Secretary and designer of the administration’s healthcare reform — was a special policy advisor, personally representing UnitedHealth Group, and keynote speaker for Ingenix.

Most importantly, Ingenix data has been used in published medical research — albeit terribly flawed — to convince Americans of skyrocketing costs of obesity, diabetes, depression, high blood pressure, high cholesterol and unhealthy lifestyles.

  • The database was used, for instance, in a recent study (covered here) that claimed that bariatric surgeries save healthcare costs and has been used to coerce private and government payers to cover the surgeries. Will this flawed research be retracted and coverage for these surgeries be withdrawn? Not likely. A search of the American Journal of Managed Care, where the research was published, finds no retraction of the study or mention that its claims were based on discredited data.
  • The database was used in a recently published study in Population Health Management commissioned by the National Changing Diabetes® Program, a lobbying organization of Novo Nordisk, Inc., to claim that undiagnosed diabetes cost the United States $18 billion in 2007 and that diabetes and pre-diabetes had cost the country about $218 billion in higher medical costs and lost productivity. This study remains prominent on the homepage of the organization’s website, with no mention it was based on discredited data.
  • In fact, this database has been used in comparative effectiveness research of nearly every Pay-for-Performance measure (called “quality” measures); of electronic medical records; and of disease management, employer wellness and preventive health programs, claiming “to contain rising medical costs.”
  • It’s been used in claims that compliance with P4P measures — for treating obesity, hypertension, hyperlipidemia, diabetes, depression, etc. — are “evidence-based medicine” and save healthcare costs.
  • It’s been used to convince the public that managed care, electronic medical records, preventive wellness and fitness, employer wellness programs and compliance with health indices save healthcare costs and that noncompliance is costing everyone.

Credible scientists knew the studies weren’t convincing, even before hearing that the Ingenix data used was faulty. But, sadly, a lot of people readily believe the claims from anything said to come from a study or research, don’t realize that all studies are not created equal, and don’t examine the studies for themselves or recognize those that were never designed to be fair tests of anything to begin with.
If understanding the differing types of studies and clinical trials feels too overwhelming, here’s a helpful rule of thumb: Anytime you hear claims of body counts — a condition or behavior kills some huge number of people a year — or price tags — a condition or behavior costs society some huge amount in healthcare costs — you’re seeing statistical manipulations based on associations (attributable risk fractions calculated from relative risks and turning them into causations). Cost estimates are most used to sell a crisis, point blame on socially undesirable lifestyles or physical features, and convince the public of the need to “do something”… under the guise of public health and the common good.
If you’ve examined the various “costs of obesity” studies purportedly showing skyrocketing healthcare costs associated with obesity, for example, you’ve caught things like:

  • failing to account for age or socioeconomic status;
  • tallying any condition that’s ever been “associated” with obesity, and even others that aren’t (like dental services and eye glasses);
  • double counting of the same conditions (with the same health risk factor used as the “cause” for as many as four different “obesity-related” diseases);
  • incorrectly defining obesity to overstate the numbers of people crossing the threshold of “too fat”;
  • piling on fallacious estimates of lost productivity and work hours;
  • citing high healthcare costs among fat people, while failing to reveal they were lower than thin people;
  • not factoring for the costs of weight loss pills, extra tests and interventions imposed on fat people and on children in mandatory obesity guidelines;
  • blaming fat people for the adverse effects of weight loss treatments imposed on them;
  • claiming fat workers cost employers more but failing to control for age, hours worked, and type of manual labor (which would reveal that fat workers actually file fewer worker’s comp claims per hour worked, have lower rates of lost workdays and lower medical claim costs than the general population of employees);
  • and failing to reveal that healthcare costs aren’t rising in numbers of cases being treated as much as rising costs per treatment — 70% of costs due to more expensive drugs and technological interventions.

No matter how well conducted a study might be, however, when the data used is false or faulty, then the conclusions reached are unsupportable. Yet, how likely will the Ingenix scandal lead to calls for re-evaluating the premises behind healthcare reform with its managed care and third party oversight and interventions to reduce the costs of obesity, diabetes, depression, high blood pressure, high cholesterol and unhealthy lifestyles?